HEAD AND NECK INFECTIONS

PRICING INFO


References:

Infection Treatment Other
Bell Palsy
American Academy of Neurology 2012 recommendations

  • For patients with new-onset Bell palsy, the following treatments are recommended:
    • NOTE: "New-onset" is typically defined as within 72 hours of symptom onset

    • Corticosteroids - should be offered; no specific dosage is recommended; trials cited in the recommendation used prednisone-equivalent doses of 50 - 60 mg a day for 5 - 10 days. ($)

    • Antivirals - might be offered; no specific dosage is recommended; trials cited in the recommendation used one of the following:
  • Up to 30% of patients with Bell palsy fail to recover full facial function
  • Corticosteroids increase the probability of full recovery by 12 - 15%
  • Antivirals have no proven benefit, but a small one cannot be ruled out [1]
  • Cause of Bell palsy is unknown, but thought to be related to herpes virus infection [2]

Infection Treatment Other
Conjunctivitis, bacterial
Generally, broad-spectrum antibiotics are prescribed

Aminoglycosides
Gentamicin (Garamycin®) ointment 1/2 inch 2 - 3 times a day for 1 week ($)
solution 1 - 2 drops 4 times a day for 1 week;
severe infection - 1-2 drops every hour ($)
Tobramycin (Tobrex®) ointment 1/2 inch 3 times a day for 1 week;
severe infection - 1/2 inch every 3-4 hours ($)
solution 1-2 drops every 4 hours for 1 week;
severe infection - 2 drops every hour ($)
Quinolones
Besifloxacin (Besivance®) suspension 1 drop 3 times a day for 7 days ($$$)
Ciprofloxacin (Ciloxan®) ointment 1/2 inch 3 times a day for 2 days, then 1/2 inch twice a day for 5 days ($$$)
solution 1 - 2 drops every 2 hours while awake for 2 days, then 1 - 2 drops every 4 hours while awake for 5 days ($)
Gatifloxacin (Zymaxid®) solution 1 drop every 2 hours while awake, up to 8 times on Day 1, then 1 drop 2 - 4 times a day on Days 2 - 7 ($$)
Levofloxacin (Quixin®) solution 1 - 2 drops every 2 hours while awake, up to 8 times on Days 1 and 2, then 1 - 2 drops 4 times a day on Days 3 - 7 ($$)
Moxifloxacin (Vigamox®) solution 1 drop 3 times a day for 7 days ($-$$)
Moxifloxacin (Moxeza®) solution 1 drop 2 times a day for 7 days ($$$$)
Ofloxacin (Floxin®) solution 1 - 2 drops every 2 - 4 hours while awake on Days 1 and 2, then 1 - 2 drops 4 times a day on Days 3 - 7 ($)
Macrolides
Azithromycin (Azasite®) solution 1 drop twice daily on Days 1 and 2, then 1 drop daily on Days 3 - 7 ($$$)
Erythromycin ointment 1cm up to 6 times a day for 1 week ($)
Sulfa
Sulfacetamide
(Bleph-10®)
solution 1 - 2 drops every 2 -3 hours initially, then taper. Treat for 7 days. ($)
Other
Polymyxin B + trimethoprim (Polytrim®) solution 1 drop every 3 hours (max of 6/day) for 7 days ($)
  • Up to 80% of acute conjunctivitis is viral
  • Bacterial conjunctivitis is typically a self-limited infection that resolves without treatment
  • Antibiotics may speed recovery time
  • No clinical evidence suggests superiority of one antibiotic over another
  • Neisseria gonorrhoeae and Chlamydia trachomatis infections require systemic therapy [4,5]

Infection Treatment Other
Herpes labialis

(cold sores)
(fever blisters)
Acute episode

Preventive therapy (chronic suppressive)

Topical
  • Acyclovir cream - apply 5 times a day for 4 days. Approved for ≥ 12 years. Indicated for recurrent episodes. ($$$$)
  • Xerese cream - apply 5 times a day for 5 days. Approved for ≥ 6 years. Indicated for recurrent episodes. ($$$$)

  • Initiate therapy at the first sign of fever blister (tingling, burning, itching)
  • Antivirals decrease healing time and speed resolution by about 1 - 2 days on average [6]

Infection Treatment Other
Otitis media

ear infection
Children (American Academy of Pediatrics recommendations)
  • First-line
    • Amoxicillin - 80 - 90 mg/kg/day given in 2 divided doses for 5 - 10 days* ($)
    • Amoxicillin-clavulanate (Augmentin®) - 90 mg/kg/day of amoxicillin, with 6.4 mg/kg/day of clavulanate [amoxicillin to clavulanate ratio, 14:1] given in 2 divided doses) for 5 - 10 days* ($)
  • Penicillin-allergic
  • Other
    • Clindamycin - 30–40 mg/kg/day given in 3 divided doses for 5 - 10 days* ($$-$$$) [7]
      • * Age < 2 years - 10 days of therapy
      • * Age 2 - 5 years - 7 days of therapy
      • * Age ≥ 6 years - 5 - 7 days of therapy
  • NOTE: Price estimates based on liquid form

Other
  • Amoxicillin-clavulanate preparations with a 14:1 ratio of amoxicillin-clavulanate are less likely to cause diarrhea than preparations with a lower ratio
  • Cefdinir, cefuroxime, cefpodoxime, and ceftriaxone are highly unlikely to cross-react in penicillin-allergic patients because they differ significantly in chemical structure [7]
  • Ear tubes are generally recommended in children with otitis media lasting longer than 3 months
  • Ear tubes are not recommended in children with recurrent otitis media who do not have a chronic middle ear effusion [8]

Studies
  • Oral Steroids vs Placebo for OM with Effusion, Lancet (2018) - Randomized, controlled trial (N=389) in children (2 - 8 years) with OM, effusion for ≥ 3 months, and hearing loss. Results: Acceptable hearing at 5 weeks was not significantly different between groups: Steroid - 40%, Placebo - 33% (p=0.16) [PMID 30152390]
  • 5 Days vs 10 Days of Augmentin, NEJM (2016) - Randomized, controlled trial (N=520) in children (6 - 23 months) with otitis media. Results: The 5-day group was significantly more likely to have clinical failure: 5-day group - 34%, 10-day group - 16% [PMID 28002709]

Infection Treatment Other
Otitis media
with TM perforation
or ear tubes

(suppurative otitis media)
First-line (FDA-approved)
  • Ofloxacin (Floxin otic®)
    • Ear tubes - Five drops instilled into the affected ear twice daily for ten days. Warm bottle first by holding in hand. The patient should lie with the affected ear upward, and then the drops should be instilled. The tragus should be pumped 4 times by pushing inward to facilitate penetration of the drops into the middle ear. This position should be maintained for five minutes.
    • Perforated TM - Ten drops instilled into the affected ear twice daily for fourteen days. Warm bottle first by holding in hand. The patient should lie with the affected ear upward, and then the drops should be instilled. The tragus should be pumped 4 times by pushing inward to facilitate penetration into the middle ear. This position should be maintained for five minutes. ($)
  • Ciprofloxacin and fluocinolone (Otovel®)
    • Ear tubes - Instill the contents of one single-dose vial (0.25 ml) into the affected ear canal twice daily (approximately every 12 hours) for 7 days. Warm the solution by holding the vial in the hand for 1 to 2 minutes. Lie with the affected ear upward. Pump the tragus four times. Maintain position for 1 minute. ($$$$)
  • Ciprofloxacin and dexamethasone (Ciprodex®)
    • Ear tubes - Four drops instilled into the affected ear twice daily for seven days. Warm bottle first by holding in hand. The tragus should be pumped 5 times by pushing inward to facilitate penetration of the drops into the middle ear. This position should be maintained for 60 seconds. ($$$$)
Other (not FDA-approved)
  • Cortisporin-TC® (colistin, neomycin, thonzonium, hydrocortisone) - otic suspension; 4 - 5 drops in affected ear 3 - 4 times a day. The patient should lie with the affected ear upward and then the drops should be instilled. This position should be maintained for 5 minutes to facilitate penetration of the drops into the ear canal. ($$)
  • Ophthalmic drops - gentamicin, tobramycin, and ciprofloxacin ophthalmic drops have been used. See conjunctivitis above. [9]
  • Ear drops are preferred over oral medications in otitis media with perforation and otitis media with ear tubes
  • Ototoxicity from aminoglycosides (neomycin, gentamicin, tobramycin) is controversial. There have been case reports of ototoxicity, but no definitive link has been established.
  • Cortisporin otic suspension is preferred over Cortisporin otic solution because it has a higher pH and may be less irritating
  • Ear tubes are generally recommended in children with otitis media lasting longer than 3 months
  • Ear tubes are not recommended in children with recurrent otitis media who do not have a chronic middle ear effusion
  • Ear plugs are not recommended for swimming, etc. in children with ear tubes [8,9]

Infection Treatment Other
Otitis externa

(outer ear infection)
(swimmer's ear)
First-line
  • Acetic acid solution (Vosol®) - insert a wick of cotton saturated with acetic acid into the ear canal. Keep the wick in for at least 24 hours and keep it moist by adding 3 to 5 drops of Acetic Acid every 4 to 6 hours. The wick may be removed after 24 hours. Continue to instill 3 - 5 drops of acetic acid 3 or 4 times daily thereafter, for as long as indicated. ($)

  • Ofloxacin (Floxin otic®)
    • Pediatric (from 6 months to 13 years old) - Five drops instilled into the affected ear once daily for seven days. Warm bottle by holding in hand before use. The patient should lie with the affected ear upward, and then the drops should be instilled. This position should be maintained for five minutes.
    • Patients ≥ 13 years - Ten drops instilled into the affected ear once daily for seven days. Warm bottle by holding in hand before use. The patient should lie with the affected ear upward, and then the drops should be instilled. This position should be maintained for five minutes. ($$, ofloxacin eye drops can be used in the ear and may be cheaper)

  • Cortisporin Otic® (neomycin, polymyxin b, hydrocortisone) - otic solution; 3 - 4 drops in affected ear 3 - 4 times a day. The patient should lie with the affected ear upward and then the drops should be instilled. This position should be maintained for 5 minutes to facilitate penetration of the drops into the ear canal. Do not use for more than 10 days. ($)

  • Acetic acid and hydrocortisone solution (Vosol HC®, Acetasol HC®) - insert a wick of cotton saturated with acetic acid into the ear canal. Keep the wick in for at least 24 hours and keep it moist by adding 3 to 5 drops of acetic acid every 4 to 6 hours. The wick may be removed after 24 hours. Continue to instill 3 - 5 drops of acetic acid 3 or 4 times daily thereafter, for as long as indicated ($$)

  • Cortisporin-TC® (colistin, neomycin, thonzonium, hydrocortisone) - otic suspension; 4 - 5 drops in affected ear 3 - 4 times a day. The patient should lie with the affected ear upward and then the drops should be instilled. This position should be maintained for 5 minutes to facilitate penetration of the drops into the ear canal. Do not use for more than 10 days. ($$)

  • Ciprofloxacin and dexamethasone (Ciprodex®) - Four drops instilled into the affected ear twice daily for seven days. Warm bottle by holding in hand before use. The patient should lie with the affected ear upward. This position should be maintained for 60 seconds. ($$$$)

  • Ciprofloxacin and hydrocortisone (Cipro HC®) - For children (age 1 year and older) and adults, 3 drops of the suspension should be instilled into the affected ear twice daily for seven days. Warm bottle by holding in hand before use. The patient should lie with the affected ear upward and then the drops should be instilled. This position should be maintained for 30-60 seconds to facilitate penetration of the drops into the ear. ($$$$)

  • Finafloxacin otic suspension (Xtoro®) - For children (age 1 year and older) and adults, instill four drops into the affected ear(s) twice daily for seven days. Warm bottle by holding in hand before use. Shake bottle well. Lie with the affected ear upward, instill the drops, and maintain the position for 60 seconds to facilitate penetration of the drops into the ear canal. ($$$$)

  • Ear drops are preferred over oral antibiotics for uncomplicated otitis externa [10]

Infection Treatment
Pulpitis

(Toothache)
  • Antibiotics are widely prescribed for toothache, or "pulpitis" which is the medical term for the condition
  • Penicillin, amoxicillin, amoxicillin-clavulanate, and clindamycin are the antibiotics that are typically used
  • No large, randomized controlled trials have evaluated the use of antibiotics in pulpitis [13]
  • One small trial involving 40 patients found no benefit of penicillin when compared to placebo [12]
  • No good evidence supports the use of antibiotics in uncomplicated pulpitis

Infection Treatment Other
Sinusitis
* Risk of penicillin cross-sensitivity is very low with these cephalosporins [15]
ADULTS - FIRST LINE
Standard (IDSA recommendations)

High-dose therapy - recommended when one of the following is present: geographic regions with high endemic rates (≥10%) of invasive penicillin-resistant S. pneumoniae; those with severe infection (e.g. fever ≥ 39°C [102°F], and threat of suppurative complications); age > 65 years; recent hospitalization; antibiotic use within the past month; immunocompromised [14]
ADULTS - SECOND LINE (PENICILLIN ALLERGIC)
CHILDREN - FIRST LINE
Standard (AAP recommendations)
  • Amoxicillin 45 mg/kg/day given in 2 divided doses for a minimum of 10 days

High-dose therapy - recommended in communities with a high prevalence of nonsusceptible S pneumoniae (>10%, including intermediate- and high-level resistance)
  • Amoxicillin 80 to 90 mg/kg/day given in 2 divided doses (maximum of 2 g per dose) for a minimum of 10 days

Moderate to severe illness - defined as the presence of one of the following: < 2 years old; attending child care; recently been treated with an antimicrobial
  • Amoxicillin-clavulanate (Augmentin®) 80 – 90 mg/kg/day of the amoxicillin component with 6.4 mg/kg/day of clavulanate given in 2 divided doses with a maximum of 2 g per dose for a minimum of 10 days [15]
CHILDREN - SECOND LINE (PENICILLIN ALLERGIC)

Young children (< 2 years old)
  • Clindamycin 8 to 12 mg/kg/day divided into 3 or 4 equal doses + Cefixime (Suprax®) 8 mg/kg/day (max 400 mg/day) given in one or two divided doses a day for a minimum of 10 days
  • Levofloxacin (Levaquin®) 8 mg/kg (max dose 250 mg) twice a day for a minimum of 10 days [15,16]
  • Antibiotic treatment in adults with sinusitis has generally been found to be no better than placebo in randomized controlled trials (see sinusitis studies for more)
  • Amoxicillin-clavulanate preparations with a 14:1 ratio of amoxicillin-clavulanate are less likely to cause diarrhea than preparations with a lower ratio
  • See Sinusitis for more

Infection Treatment Other
Strep throat
First-line (non-penicillin allergic) - IDSA recommendations
Medication Pediatric dosing Adult dosing Duration/Price
Penicillin
(Pen VK®)
250 mg twice daily or 3 times daily 250 mg 4 times daily or 500 mg twice daily 10 days ($)
Amoxicillin 50 mg/kg once daily
(max = 1000 mg/day)
25 mg/kg twice daily
(max = 500 mg/dose)
1000 mg once daily or 500 mg twice a day 10 days ($)
Penicillin G benzathine
(Bicillin L-A®)
< 27kg - 600,000 U;
≥ 27 kg - 1,200,000 U
intramuscular
1,200,000 U intramuscular 1 dose ($$-$$$)
Penicillin allergic
Medication Pediatric dosing Adult dosing Duration/Price
Cephalexin*
(Keflex®)
20 mg/kg/dose twice daily
(max = 500 mg/dose)
500 mg twice a day 10 days ($)
Cefadroxil*
(Duricef®)
30 mg/kg once daily
(max = 1000 mg)
1000 mg once daily 10 days ($)
Clindamycin
(Cleocin®)
7 mg/kg/dose 3 times daily
(max = 300 mg/dose)
300 mg three times a day 10 days ($-$$$)
Azithromycin
(Zithromax®)
12 mg/kg once daily
(max = 500 mg)
500 mg once daily 5 days ($)
Clarithromycin
(Biaxin®)
7.5 mg/kg/dose twice daily
(max = 250 mg/dose)
250 mg twice daily 10 days ($-$$)
  • * Do not use in patients with immediate-type hypersensitivity to penicillin
  • Reference - 11


Infection Treatment Other
Thrush

(oral candidiasis)

Pediatric


  • Infants
    • Nystatin suspension 100,000 units/ml - 2 ml (200,000 units) four times a day. Place 1 ml in each side of mouth and avoid feeding for 5 - 10 minutes. Continue treatment for at least 48 hours after lesions have disappeared. ($)
  • Children
    • Nystatin suspension 100,000 units/ml - 4 - 6 ml (400,000 - 600,000 units) four times a day. Solution should be swished and swallowed. Retain in mouth as long as possible. Continue treatment for at least 48 hours after lesions have disappeared. ($)

Adults


  • Clotrimazole troche (Mycelex®)
    • Active infection - place one troche (10 mg) in mouth and allow to dissolve five times a day for 14 days ($-$$)
    • Prophylaxis (e.g. chemo, radiation) - place one troche (10 mg) in mouth and allow to dissolve three times a day for duration of therapy ($+)
  • Miconazole (Oravig®) - apply one buccal tablet (50 mg) to the upper gum once daily for 14 days ($$$$)
  • Nystatin suspension 100,000 units/ml - 4 - 6 ml (400,000 - 600,000 units) four times a day. Solution should be swished and swallowed. Retain in mouth as long as possible. Continue treatment for at least 48 hours after lesions have disappeared. ($)

All dosing recommendations are from the drug's package insert
  • Thrush is caused by Candida sp, most commonly C albicans
  • Risk factors include advanced age, dentures, diabetes, immunocompromised state (e.g. HIV/AIDS, cancer, chemotherapy), steroid inhalers, antibiotic use, Cushing's syndrome, salivary gland dysfunction (e.g. Sjögren's syndrome, radiation to the head and neck) nutritional deficiencies, high carbohydrate diet, and smoking
  • Other conditions that can present as white patches in the mouth include lichen planus, squamous cell carcinoma, lichenoid reaction, and leukoplakia
  • Thrush lesion can typically be scraped off to expose underlying erythema
  • Patients with thrush should practice good oral hygiene including regular brushing of the teeth, gums, and mouth, cleaning and soaking dentures, and removing dentures at night
  • In rare cases, systemic therapy may be necessary [20]